What is the best next step in the management of this patient?
a. Chest radiography
b. Blood cultures
c. Start antibiotics
d. Sputum culture
e. Check for a cough
Answer a. Chest radiography The best next step in the management of this patient is to obtain posterior-anterior and lateral chest radiographs. It is always the wrong answer to obtain a portable chest radiograph for anything other than line or tube placement. Obtaining blood cultures will not help in diagnosis pneumonia but only for bacteremia, and starting antibiotics is only after the pneumonia is confirmed. Sputum is only available in up to one third of patients with pneumonia, and therefore it is not routinely done. Cough is not necessarily seen in all patients with pneumonia and therefore is also not reliable for diagnostic purposes.
Order: • PA and lateral chest radiography Turn the clock forward to obtain results. CCS TIP: The exam will always tell you exactly what time the report will be available. The chest radiography reveals a dense consolidation in the right lung base consistent with aspiration pneumonia.
Interleukin 1 (IL-1) release causes fever by stimulating the hypothalamus.
Benefits of fever: • Increased mobility of leukocytes • Enhanced leukocyte phagocytosis • Decreased endotoxin effects • Increased proliferation of T cells
Order:
• Antibiotics to cover for health care–associated pneumonia (HCAP) regardless of the postoperative day.
Surgery or intubation makes HCAP possible even before the 48-hour mark.
CCS TIP: After you order the correct antibiotics, turn the clock forward, and the case will end.
Treating HCAP when pseudomonas is likely requires vancomycin with two of the following: • Antipseudomonal cephalosporin (cefepime, ceftaroline) • Carbapenem (imipenem, meropenem) • β-Lactam/β-lactamase inhibitor (piperacillin–tazobactam, ticarcillin–clavulanic acid) • Fluoroquinolone (levofloxacin, moxifloxacin) • Aminoglycoside • Monobactam (aztreonam)